The Good Journey at ACPE

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My Ride

More than three years ago I began two projects, one personal and one professional. I started full-time work as ACPE’s first physician CEO, and I began restoring an old Toyota Land Cruiser. As my last day at ACPE approaches, I’m thinking about the similarities between those projects.

Both ACPE (1975) and the old Cruiser (1979) were born about the same time. In geologic time, both came into existence before Mt. Saint Helens erupted. In political history, both were new during the first oil crisis in the US in 1979.

The craftsmen and women who built these legendary entities had pride and vision for the future. The core components of each (physician leadership education; classic 4WD mechanical components and reliability) deserved to be retained. But after more than 30 years of change and progress, each required some remodeling to needs of today.

For the Cruiser, my son and I found a diesel engine to replace the old, inefficient gasoline engine, and decided to repair a few other things that needed attention. Little did we know that a LOT more parts needed an upgrade. The short version of the restoration is the cover story in the Winter Edition 2011 of the magazine 4x4 Garage.

Brake lines needed to be replaced. Damage from boulders hidden under layers of bondo required new sheet metal and welding. The transmission frequently popped out of first gear on steep downhill grades.

We found a Toyota diesel mated to a more modern 5-speed transmission from Australia. That nearly tripled the gas mileage, and the added turbo now makes for a quick old 4 x 4! We found a canvas top made only in Pakistan (by a company owned by Ehsan - a physician) that’s an exact replica of the original Toyota soft top. We had help from several people across the globe with far more expertise than either of us. We shared our mistakes, and admitted what we didn’t know. Actually, it was my son who did most of that on his build thread on the online forum IH8Mud.

The venture into social media meant the world was able to see what was happening in my New Mexico mountain shop. Those connections brought us into contact with many interesting, courageous and creative people.

Meanwhile, at ACPE, we began the process of imagining what a more modern College might look like for physicians with a passion for learning, leading, and innovating. We got rid of some old traditions, such as tuxedos and evening gowns for the Induction Ceremony. We switched from paper ballots to on-line voting for ACPE Board candidates. We made some changes to our board: adding ex-officio members with younger and different perspectives.

Our board, blessed with some very strong Chairs during my tenure, grappled with what author Jim Collins called the Hedgehog Concept: What are we passionate about? What can we be the best in the world at? What drives our economic engine?

On the day I signed my contract to become CEO, Lehman Brothers collapsed. The early months of the recession forced us to develop a more efficient engine. That modification continues to get high miles per gallon since the recession has eased, and will serve the College well in the years to come. Dr. Peter Angood, who will begin on November 15, will be able to install the turbo charger for the next phase at ACPE, and maybe change the sheet metal for the next model years!

Your staff and I had help from many of you in this “resto-mod”. Through the Board Task Forces, expanded networks, and feedback on surveys, we found new curriculum, faculty, and topics that led to lively sessions, and even a new certificate program (HIT).

The Physician Executive Journal of Medical Management became PEJ. The topic of physician leadership made it to the Wall Street Journal, New York Times and NPR, indicating greater relevance for the College and its members.

I’m going to write one more blog for ACPE before I leave for the next phase of my life after our Board meeting at the Fall Institute in Scottsdale next week. For those of you who find yourself in a CEO role someday, I want to share some of the important lessons I learned about the unique challenges inherent in “the corner office” – even though there are no corner offices in the cylindrical building that houses ACPE headquarters here in Tampa.

If you see the sky blue Cruiser with the Pakistani soft top somewhere in the U.S. over these next few years, wave to me and smile.

The Situation at Pumpkin Springs

On day seven of my raft trip down the Colorado River at the bottom of the Grand Canyon last week, our group came to a popular stopping point called Pumpkin Springs. The rocks just above the hot springs was a place to jump into the dangerous and exciting Colorado River for a cool, refreshing diversion from the hot sun of the mid-afternoon.

Our guides noted that the landing here would be difficult because it required landing just above rapids. They told all of us to disembark from the rafts with our life vests on, should we fall into the fast moving river just above the rapids.

No one wanted to go into Pumpkin Springs because of rumored high levels of arsenic. It didn’t smell very good, either. But some wanted to do the jump into the river – including me. What happened next surprised me, and taught me a few lessons about taking chances in a group.

We climbed to the rocks overlooking Pumpkin Springs. The guides pointed out the jumping spot and the water below, noting that the life vests caused you to pop right up out of the water, and the prevailing eddy current would actually pull you back upstream to a nook in the rocks – and a rope to climb back up. One of the guides jumped to demonstrate the deep water below, and the route to the rope.

Then came the question, “Who’s going to jump?” Several people announced quickly that they were not jumpers. I didn’t say anything. I was thinking about it. Then I uttered, “I think I will.”

I watched as my friend and fellow physician Howard leaped off the rock to the muddy water only about 12 feet below. He popped up just as predicted. His nose was bleeding. His fingernail caused a superficial laceration when he grabbed his nose to prevent water from going up his nostrils.

My turn. I’ve jumped before from similar heights – but that was about four decades ago. Standing on that rock, looking down at the swirling water only 12 feet below, I could not make the leap. Step up, look down, back off. Repeat sequence. I have no idea how many times I did that dance. My legs were shaking. I could feel the adrenaline rush that comes from fear.

Of course it didn’t help that others in the group were watching my agony. What if I got hurt on the landing? Hours away from any kind of rescue. One of my friends pointed out that I have good health insurance - the moral hazard reason to do something risky.

Another said he was beginning to question my manhood. That always comes up in a group of men – for just about any issue!

I just could not visualize myself in the air, landing feet first and entering the water straight. Then another member of the group decided she couldn’t wait any longer to jump. Watching her helped me visualize what I must do. I was finally committed. I jumped. Easy. Good landing. The current brought me back upstream to the rope, just as the guides mentioned.

Climbing back up to the rock, I jumped again with no hesitation. The cold water felt very refreshing. My agony of fear and indecision was over. Even my manhood was back!

Then I noticed that the eddy current on the first jump that pulled me back upstream – away from the rapids - was different. It was moving me downstream! I swam hard just to stay in place. Finally I made some headway and was able to get back to the rope. When I got back up to the rock, I asked Howard, who had jumped again, if he had the same problem with the current. Out of breath, he said the same thing happened to him. In the cold water longer than anticipated, he was getting cold. We decided not to jump again.

Commitment is important. If you’re not ready to do something, don’t announce that you’re “thinking about it”. It’s hard enough to understand what’s going on in your own mind when faced with a risky decision, and even harder for the group watching to understand what’s behind the indecision. Rumors and assumptions can be quite interesting! Actions do speak louder than words – to yourself, and to others.

Once you’ve taken that initial risk, sometimes everything goes as predicted – but sometimes it doesn’t. There are often unanticipated challenges and dangers. Don’t be afraid to talk about those unexpected events with others in your group. Base your next decisions on the “current conditions” you’re experiencing. Trust your instincts. Maybe my initial fear was justified after all.

Seeking -- And Finding -- Physician Leaders

One of the more interesting and active discussions in our ACPE Network is about “Why aren’t physicians leading?". You’ll find all sorts of opinions and insight. I want to submit the opposite hypothesis: that physicians ARE leading. And doing it very well!

Here are just some of the recent pieces of evidence that demonstrate the effectiveness of physicians when they are in leadership roles:

1. The New York Times' health blog picked up Amanda Goodall’s newly published research in the journal Social Science and Medicine, in which she looked at the credentials of CEOs at US News and World Report’s Top 100 Hospitals for Cancer, Heart, and GI care. Though the numbers of physician CEOs in American hospitals is low, there was a strong correlation with physician leadership in the top performers. In fact, quality scores were 25-33 percent higher in the physician led hospitals than their non-physician led peers. Like basketball teams and research universities that she’s studied, which show that former players and researchers get the best results when they are in charge, the experience of being a physician adds a powerful dimension to leadership and results in health care organizations. Read about it here.

2. The recent US News and World Report ranking of the nation’s top hospitals was released last week. Of the top ten, nine are led by physician CEOs. Going down the list of Honor Roll hospitals, eleven of the top seventeen are led by physicians.

3.The American Hospital Association recently announced it was forming a leadership forum for physicians. This effort, led by physicians John Combes (a CPE) and Bill Jessee (last year’s ACPE Distinguished Fellow), has twenty other physicians on the Advisory Board. As we read the list of names, we noted that at least 75 percent are ACPE Members, CPEs, former faculty, or use ACPE as partners in their organization’s leadership development programs. Long-time ACPE faculty member and internationally-known leader in quality and safety – David Nash – was the keynote speaker for the physician leadership forum. It’s too early to know where this initiative is heading, but knowing the integrity and experience of the group, their leadership gives me confidence that the right topics, discussions, and recommendations will be made.

4. Anecdotally, we’re hearing from recruiters that health system boards are changing their views of physicians as leaders. Ten years ago, a token physician CEO candidate was requested. Five years ago, a physician candidate would be given serious consideration. Now physicians are preferred.

I have no doubt the growing evidence of physician leaders’ effectiveness will ruffle some feathers in the health care industry. As Dr. Goodall points out in her research, there’s a strongly held belief that doctors can’t manage or lead. I believe it’s true that the vast majority of physicians do not aspire to be in the CEO’s chair of a health system. It’s darn hard work that requires a certain personality and multiple skill sets. But for those who do find themselves attracted to that role, isn’t it time that they be given a chance by governing boards, and/or groomed for the role by their current health system senior leaders?

I heard recently from a highly reliable source that most hospital CEOs do not have an internal succession plan for their replacement. Well-run businesses outside of health care consider promoting internal talent, and grooming potential successors, as a key to the long term success of the enterprise. Does health care fail to do this because the average tenure of a CEO is just under four years? Or because fifty-seven percent of hospital CEOs have been in their jobs less than five years? Do physician leaders at the top performing hospitals view training potential successors as a priority?

As we look more deeply at the characteristics that make physicians particularly good leaders, we’ll be asking questions like these, and searching for metrics to show the differences. We don’t know what we’ll find, but that’s what research is all about!

Disruptive physician or threat to the hierarchy? Watch out for the Kool-Aid

No doubt you’ve been aware of the latest survey on the topic of disruptive behavior in health care. The results of our joint study with QuantiaMD are the same as our ACPE survey nearly two years ago. We physicians still have a lot of work to do in our own house to solve this patient safety issue. We’re making progress. But it’s time to look at another angle of how physicians become labeled as “disruptive”. Sometimes the label is just plain wrong. Like old Hollywood westerns, or Patrick Swayze movies, the hero is often bullied by powerful people and organizations who feel that their authority is threatened, or who perceive that the status quo might change.

Since this latest study was published, I’ve had lots of interesting discussions with physicians, and senior health system leaders. Some senior leaders who come from non-health care industries comment on the odd culture of health care compared to many other industries. They point out (it’s also my experience) that disagreement, rather than being viewed as a strong cultural attribute for innovation and change, is frequently considered a threat to the hierarchy. Sometimes decision-making is highly centralized in the C-suite, and leaders are very uncomfortable with questions or differing opinions. In these health systems, the organizational Kool-Aid demands “loyalty” to the leaders, rather than legitimate, truthful debate about the merits of strategy, policies, or procedures. More about “loyalty” later!

When faced with a physician who voices distaste with the Kool-Aid of mindless agreement, these leaders label her/him “disruptive” – not because of behavior, but because of disagreement! That can lead to all sorts of problems for the physician who must then answer to the official organizational procedures for dealing with the disruptive physician, such as medical staff or legal proceedings.

In my first health system leadership job, I remember asking the senior physician leader of the system what Dr. X thought of the strategy proposed.
“He disagrees with us, so we’ve removed him from the committee.”

Dr. X was a physician who was respected and admired by his peers, by the nurses, technicians, and support staff who dealt with him, and most importantly, loved and respected by his patients. At least he wasn’t officially labeled disruptive, and made to go through counseling or monitoring! His disagreement with the strategy was shown to be correct a few months later.

Another physician with the same excellent clinical and service reputation came to me looking for a job. He’d been fired from another system because he disagreed with administration, sometimes too aggressively and disrespectfully. After listening to my new management colleagues advise against hiring him, and sharing my obvious concerns with him about his behaviors around managers or executives, I hired him. His dedication to patients, and his remarkable creativity were the characteristics my physician group needed. Working with him to change his behavior when he became frustrated or angry, he gradually learned how to use more productive behaviors. He got his 5-year pin, and eventually was named physician of the year by a well known national health care organization.

Both of these physicians were labeled as cynics by those who didn’t appreciate their disagreement. The best definition of a cynic is “a passionate person who doesn’t want to be disappointed again.” (Benjamin Zander, conductor of Boston Philharmomic) I learned that disagreement, when respectful and done in the spirit of innovation and improvement, is good. It’s what I like about working with talented and passionate people. It should not be extinguished. It should be encouraged.

If you hear your senior leader ask for “loyalty” – watch out! It’s just another way to stifle honest disagreement, or can be viewed as bullying.

I’ve never forgotten what I was told by a senior legal counsel in one of my first health care jobs, “Sometimes loyalty is more important than telling the truth.” Not for me.

You can hear the word “loyalty” used when uncomfortable decisions are made without the input of experts, when leaders don’t want to be questioned, or in a complex situation with public relations implications is unfolding. I don’t believe that a leader should ask for loyalty from followers. Loyalty can only be given freely by those who choose to follow, not forced upon them by a leader. Maybe if you run a monarchy or dictatorship it’s OK to ask for loyalty.

This quote from Col. John Boyd helps me put the issue of loyalty in proper perspective:

“If your boss demands loyalty, give him integrity. But if he demands integrity, give him loyalty.”

What do you ask of your team?

The Tyranny of Infallibility

Why is it so hard for we physicians to acknowledge that we’re human, prone to mistakes, misstatements, lapses in judgment, fatigue, or failure? I’ve had a most amazing week criss-crossing the country, doing presentations and having discussions with very interesting people.

One of those people was Jeff Skiles, co-pilot of USAir Flight 1549 that landed on the Hudson River in January 2009. I guess we say “on” instead of “in” because it didn’t sink - for awhile, at least. In the year and a half since I’ve known Jeff, he’s developed a very effective presentation on the impact of moving from autonomy to teamwork in commercial air transport. It’s that teamwork which contributed to the miraculous result for the passengers and crew.

A key point of Jeff’s comments is acknowledging fallibility, and dealing with it by building a team of people who learn how to communicate without “taking it personal” when they’re questioned by a team member. He said authority used to be based on fear or intimidation by the senior pilot. It’s now role-based authority.

When Capt. Sullenberger declared, “my aircraft” after the A320 hit the geese (Jeff was flying the plane), it was clear that the captain was taking responsibility for bringing the aircraft down. Jeff would go through the checklist to start the engines, if possible. Once it was clear that a crisis was occurring, the cabin crew began their respective autonomous actions to secure the cabin.

Jeff says his training in aviation comes in handy in his other roles as general contractor, husband and father. Now that’s a powerful testament to the effectiveness of these concepts!

I joined other ACPE faculty for some on-site teaching last week, and the topic of human error was discussed as a key component of the engineering science of reliability. I don’t know about you, but my instinct from years of being a physician is to believe that “human error” doesn’t apply to me – I’m a physician and not supposed to be fallible like other humans. That’s crazy!

Once we start talking about human error and the physician’s role, whether in full time clinical practice, or in system leadership, typical comments turn to our inability to admit we make mistakes because of the legal system. Are we using the legitimate but separate issue of the tort system to avoid discussion of our own human foibles, and appropriate methods of building safer care? Maybe we could find humor in our foibles, and have some fun with the topic instead of avoiding a necessary discussion!

Like many of you, and like some of the physicians with whom I teach, on certain occasions I’ve deliberately ignored the advice of a malpractice attorney to not admit I made a mistake in diagnosis or treatment. Knowing the truth of what happened and my role in it, withholding that truth from any human being isn’t right, and it eats away at me.

Most studies of physicians conclude that we do not like to be controlled or directed by others. If we don’t like the control that the tort system and lawyers have over us, then why do we exhibit learned helplessness by agreeing with them that we must not admit our fallibility?

Frankly, it’s liberating to discard the illusion that I should be immune from human error and weakness. That holds true for both clinical care, and in leadership or management roles. It’s self-imposed tyranny to think otherwise. Best yet, I believe that the key to improving safety, reliability – and changing the tort system – is in throwing off the chains of infallibility and perfection that we expect of ourselves, and adopting many of the concepts that helped other industries become much safer.

Notes from the San Antonio Annual Meeting

ACPE's Annual Meeting, held in San Antonio, ended this past week. The participants had an energy, enthusiasm and passion to improve health care that was noticeable to me and the ACPE staff. Here are some comments and observations from the meeting, in no particular pattern, that might be helpful in your daily activities. These thoughts might also help you put the current uncertainty of health care in perspective.

• Kevin Fickenscher, long-time ACPE member and editor of Dell's Washington Report, noting in his Vanguard presentation that in 2009, the federal government collected $1.3 trillion in taxes; expenses for Medicaid, Medicare, Social Security and service on the national debt totaled $1.2 trillion. We borrowed the rest.


• David Nash, dean of Jefferson University School of Population Health, who has an uncanny knack for sound bites, shared his new four word summary of Accountable Care Organizations: "No outcome, no income."


• Grace Terrell, CEO of Cornerstone Health Care in High Point, N.C., and Sue Freeman, CMO at Temple University in Philadelphia, both commented on facilitator Francine Gaillor's thought-provoking statement that "leadership is a stage." Everything a leader does is under a spotlight. Your words, actions, body language and moods are constantly on display. How does your performance come across to your audience?


• Chal Nunn, CMO of CentraHealth in Lynchburg, VA, commenting in a break-out session on quality and safety: "A 99-1 vote is considered a tie by the medical staff."


• One of the participants in the same break-out session commenting on the challenges in getting agreement by the medical staff, got a big laugh when he mentioned, "the 'silverback male' on the medical staff can derail the best laid plans."


• John Kenagy -- surgeon, author, advisor and keynote speaker -- outlined his concept of Adaptive Design, which allows front-line workers to rapidly and energetically spot and solve problems on their own. No layers of bureaucracy and hierarchy needed! Several attendees commented on how useful the A3 Problem-Solving Report will be in developing operational plans to resolve problem areas in their workplaces.


• Tom Royer, physician CEO emeritus of Christus Health System, gave a moving address to the new CPEs and Fellows at the Induction ceremony. Relating several poignant moments in his leadership career, he asked all of us to ponder why we're put on the earth, and to appreciate the opportunities we have to help others.

Now we're changing our focus to the Summer Institute in Boston, July 15-19. In addition to our Integrated Health Systems course, which covers everything from strategic considerations to physician engagement to financial integration, we're launching a new course on entrepreneurial thinking. This new course was developed in response to one of our ACPE Board Task Force's recommendations. It will be taught by the director of the Entrepreneur Program at the University of Southern California's School of Business.

Bostonians say the snow has melted and that summer is a great season to visit their historic city. If you haven't ridden the water taxi there, I can highly recommend the experience as a cool summer mode of transportation.

The Bus or the Rope?

How many times have you heard leaders talk about “getting the right people on the bus”?

I find that analogy in health care to be difficult. It just doesn’t resonate with my experiences or my sense of how we should be thinking of our work on behalf of patients. First, let me outline why the “bus” and its occupants makes me uncomfortable. Then I’ll outline a model that makes more sense to me.

Ask a group of physicians or executives where they’ll be sitting on that bus if they’re the leader. The immediate and most common response is, “In the driver’s seat, of course! I know where I want to go and how to get there. I want people on the bus who support my direction.”

A few want to sit in the back and monitor what’s happening as the bus barrels down the freeway. Some are comfortable with rotating drivers.

Are riders on your bus comfortable pointing out problematic strategic, operational, or patient safety-related decisions? What do you do if your riders disagree with you? Usual responses: “They’re asked to get off the bus” or “They’re thrown under the bus!”

Ask about where the patient rides on the bus. That question gets some very interesting responses: “Somewhere behind the driver”; “In the driver’s seat”; “In the baggage compartment.” That last response gets a lot of laughter, and heads nodding in agreement.

Now imagine a different image. Imagine you, your team of health care professionals, and a patient are on a rope, climbing a mountain in the Rockies, Andes, or Himalayas. You are all linked together on that rope, all with the same goal. In health care, it might be evidence-based medical care, highly reliable and safe care with optimal outcomes, or patient centered care. It’s risky work. There might be many ways to get to your collective goals, but it will require input from everyone.

It might also require vigorous disagreement from time to time about the safest and best way to proceed. If you’re the leader of the team, and know how you want to achieve your goal and how fast you want to get there, are you comfortable with agreement, or perceived agreement? No one speaks up. Do you assume everyone agrees? Do you want to encourage disagreement before starting up that dangerous part of the journey?

As you proceed up that mountain, you’re about to step in a crevasse. We’re all prone to mistakes as human beings. How do you want the team member behind you on that rope to respond? I want to hear, “STOP – that’s not safe!” Or feel the sudden tightening of the rope as an ice axe is plunged into the snow. We’re all in this together – each one of us concerned about one another’s personal and professional safety – regardless of our status in the hierarchy of the team. What happens to one of us is likely to happen to everyone else on that rope.

Finally, imagine a situation where the patient is the only person on the rope who isn’t ready, or in shape, for the push to the top. Not strong enough. Circumstances don’t seem auspicious or comfortable. Do we have the courage, compassion, and situational awareness to listen? Do we decide to wait until another day or moment, or do we drag the patient up to the top because the health care team believes it’s the right thing to do?

Put me on a rope with people who aren’t shy about voicing their concerns for patients, and for safety. People who can be counted on to do what’s right, for the right reasons. I don’t mind if those people are a little rough around the edges. If everyone realizes that the most important individual on that team is the patient, we’ve got a great team! Come to think of it, maybe that patient is the true leader of the team.

Physicians and Disruptive Innovation

Last week, ACPE Vice President of Career Services Barbara Linney hosted a webinar on career options that broke previous attendance records. This one was notable for the number of physicians looking outside the hospital sector for new roles. Consulting, insurance, pharma, or entrepreneurial ventures were mentioned as preferred destinations.

I’ve been racking up frequent flyer miles the past few months doing on site training on clinical leadership and moving from autonomy to teamwork in a health care system undergoing stress and change. If energy, enthusiasm, and engagement of the audience is an indicator of most physicians’ state of mind, it appears that many are thinking about what they can do beyond individual patient care to provide remedies for a broken system, and to get more satisfaction from their professional careers.

The topic of disruptive innovation generates the most animated discussion. They’ve been giving thought – when they can steal a few moments from their roles as production workers in the fee for service system – to what they would change, and the technologies or business models that would help them do just that.

Just as we talk of the ACO concept as moving from “volume to value” for consumers and purchasers, clinicians are thinking how they can provide value beyond their role as patient care “volume producers”. Henry Ford’s comment about the people wanting “a faster horse” before his disruptive innovation of the Model T resonates with physicians. Most don’t believe they can be a “faster horse” in their practice situations. They cite patient safety and quality as their first concerns. Our pledge as physicians to “first, do no harm” is jeopardized.

John Agwunobi, a long time ACPE member and Senior Vice President at WalMart, made some very insightful comments last week on a conference call with us here in Tampa. John is using his background as a MD, MBA and MPH to change the status quo through his role at WalMart. The joint announcement by WalMart and First Lady Michele Obama last week about reducing salt, sugar, and fat content of foods sold at WalMart as one step to improve the health of our population is just one example of that.

John (and I) encourage you to think of being a physician as just the start of your lifelong journey of learning, improving health, and making a difference in people’s lives. Your clinical experience is a foundation for adding new competencies that will give you new opportunities to improve health and health care. Imagine what you might be doing if you didn’t view being a physician as your only identity, or the only valid destination for your learning and education!

Would you learn how to incorporate engineering principles of reliability and safety into patient care? How about learning how to lead people from different professional backgrounds? Does disruptive innovation appeal to you? Starting a new business, or improving the business we’re in? Studying behavioral economics to find ways to change our population’s unhealthy lifestyles and habits?

Like you, I’m proud of my path to becoming a physician, and honored to be recognized as such. Paradoxically, recognizing that there are many other people and professionals – besides physicians - who make important contributions in our society and work just as hard, helped me put my “physicianhood” in proper perspective. It was the foundation to build on – not the ultimate destination in my life.